374604264-5-17-2024-08-AS-LTEZ-D5HV48-20240522160556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604264
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:31:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2024 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20240506103142

FACILITY NAME:	NIR COMMUNITY III		FACILITY NUMBER:	374604264
ADMINISTRATOR:	HUQ, RANA		FACILITY TYPE:	740
ADDRESS:	10975 JANICE CT		TELEPHONE:	(858) 414-5095
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92126
CAPACITY:	6	CENSUS: 5	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Staff, Conchita Gallardo		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Licensee did not treat pest

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Staff, Conchita Gallardo.

During the investigation, the facility was toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the licensee did not treat pest. It was reported a cockroach was observed in Resident #1’s (R1) cup and around the room approximately two (2) to three (3) months ago. It was also reported the roach was observed two (2) weeks ago. Conflicting statements were made. Staff interviews revealed they have not observed any pest or roaches. However, they are taking precautionary measure by spraying inside and outside of the facility once a week. Outside sources revealed the roach was observed but it was only one (1) time a few months ago and there have not been any other observations of pest or roaches. Resident interviews confirmed there were no pest or roaches observed in the facility. Continued on an LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240506103142

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NIR COMMUNITY III	FACILITY NUMBER: 374604264
	VISIT DATE: 05/17/2024

NARRATIVE

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On 05/15/24, LPA toured the facility and observed private and common areas, no pest or roaches were observed. The licensee stated they have not observed any pest or roaches but will be having a professional extermination company coming to the facility as a precautionary measure due to the weather changing, which can bring out pest.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to
Staff, Conchita Gallardo whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

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